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HomeMy WebLinkAbout2025-00067829 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 010 II IIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003993661 u, 1 U21 2 4 1 u,99 U299 u, 1 u2 1 u, 1 U2 1 1 10 u, 4 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00067829 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rI ® ❑ RELATED ®Y 0 N 10 17 2025 ®AM ❑YES ®NO U1 W HIGHLAND AVE Elgin 07:09 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III FT!MI N E S W N LYLE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N O 0 T-NONE TOWED U1 O NAME(LAST,FIRST.M) Pennings. Karen.A. mo yr Ford Bronco 2021 2 DUE TO CRASH ❑© EN 13-UNDER CARRIAGE 16 1 • 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 ITI F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I,.4 COM VEH 0 0 1 0 F. FIRST CONTACT 12 7 ;—, _5 *IIYes.See Sidebar U1 Z Gilberts IL 60136 0 1 0 1228572 IL 2025 REAR TELEPHONE IL D 0 3FMCR9B67MRB19089 American Family ❑Y ®N U2 II' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 011141180348fppail 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 c p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 Kxv 0 Dv yr ��j t2 2 FIRE ®❑ ® U2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistraetlon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 j( 4 COM VEH D ® U1 CO FIRST CONTACT 3 Y.'_, -5 •If Yes.See Sidebar 4 ELGIN IL 60123 0 1 0 588AC790 IL 2026 REAR 0 IL D 0 3FADP4EJ4FM211140 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X Same j813871d0113c SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 05 / M 2 5 B 1 0 RI / / #OCCS > / / U1 1 D / / 2 O EV MOST EVNT LOC. DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 11 1 10/17 /2025 07 09 0 PM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n T ✓ 1 2 ❑ 2 99 / / ❑PM ❑Construction c Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 -a, N ARREST NAME / / ID PM ' 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT o SECTION CITATION NO. ROAD CLEARANCE TIME • 0 AM 30 t 2 ElARREST NAME 10/17 /2025 08 00 M PM 0 Unknown work zone type u, n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 30 1531 SchE mbach.Jack sot / / 0 PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- ;.--_.r-_--; N combination):or —I INDICATE NORTH p1 J I L,_ II BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ (example:shuttle or charter bus):or X L <--- ---.; I Not To Scale - transportng employeeslin the courses o rhea emaployment example:employee a contract ner } } } tra3.nsporter-usually a van Type vehr icle or passenger car):or C L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N } } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L--_-a-___. L 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires -u ._r I 1`" — — — placarding(example:placards will be displayed on the vehicle). XI m i > I`I CARRIER NAME Z ADDRESS n T. C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I rlir . . . . - ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Red Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE